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Home
Who are we?
What we help with
Individual, Couples & Family Therapy
Low-Income Therapy
Our Approach
Therapy
Blog
Our Mission
Neurodiversity Training
Contact
Contact Form
Provide the title of the quiz form here
Low-income counselling intake form
Please fill out this form to access the low-income counselling program.
Get started
Are you in crisis? (If so, please discontinue this form and contact a crisis line like 988)
No
Is there something else youd like to tell us?
Do you identify as Neurodivergent (ie autistic, live with ADHD, OCD, Bipolar, etc)?
Yes
No
Are you an adult (19+)?
Yes
No
Do you live in Ontario or BC?
BC
Ontario
Other
Do you have insurance that supports counselling?
Yes
No
What would you like support with?
What is your household's annual income?
Contact Information
This is a contact form. Please provide your contact information below, and we'll get in touch to assist you with any questions or requests you may have.
Full name
Phone number
By checking the nearby box, I acknowledge that I understand the following:
Information submitted through this form is collected for the purpose of responding to your inquiry, determining program eligibility, and facilitating counselling intake where appropriate.
By submitting this form, I consent to the collection and use of my personal information for these purposes.
I understand that this form is not intended for the sharing of urgent or highly sensitive clinical information. While Neurodiversity Aware Counselling takes reasonable steps to protect your privacy, online forms are not fully secure communication channels.
I understand that form data is stored on secure third-party platforms used to support clinic operations. Information will only be accessed by authorized staff and clinical supervisors where necessary and will not be shared externally without my consent, except where required by law.
If you are experiencing an urgent mental health crisis, please contact 988 or local emergency services rather than using this form.
For questions regarding privacy or data handling, please contact: info@neurodiversityawarecounselling.com
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